+/- Opioid Management

Kristen Zeller, M.D.Interventional Pain

Management Specialist

• Pain – “Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”

*1994 International Association for the Study of Pain

Basic Neuroanatomy of Pain

Biochemical mediators of the Dorsal Horn

• Excitatory Neuromediators

-Excitatory amino acids-glutamate and aspartate

-Neuropeptides-substance P (SP) and calcitonin

gene-related peptide (CGRP)

-Growth Factor-brain-derived neurotrophic factor

(BDNF)

• Inhibitory Neuromediators

-Endogenous opiods, such as enkephalin and

B-endorphin

-Gamma-aminobutyric acid (GABA)

-Glycine

Yin/Yang

1. Excitation occurs in an injury

2. A patient needs counter balance or pain can be out of control

3. Patients have natural inhibition

4. Opioids particularly in an acute injury function as inhibition in the pain pathway

Target Sites for Pain Therapies

Individual Pain Experience

Nociception Perception of Pain

Suffering Pain Behavior

Fear

Secondary Gain

Cancer

Depression

Nociception

Perception of Pain

SufferingPain Behavior

Nociception

Perception of Pain

Suffering Pain Behavior

Fear

Secondary Gain

Depression

High Pathology

ACUTE PAIN

CHRONIC PAIN

Low Pathology

OPIOID MANAGEMENT

PAIN

OPIOIDS

DIAGNOSIS

OPIOID MANAGEMENT

DIAGNOSIS ?

SOMATIC (Acute post-op,

Fractured bone, Cancer

metastasis to the bone, etc)

NEUROPATHIC (RSD, Neuroma, Peripheral Neuropathy, Radiculopathy, etc.

VISCERAL (Distention of hollow viscous, SBO, etc.

Very Helpful ? Utility ?Utility

OPIOID MANAGEMENT

• AGE ? - Is tolerance going to be an issue

• Pathology ? - Chronic benign pain with low pathology

• Chemical Dependency ? – Denial - Urine Screen

• Functional ability ? – Coach Potatoes

• Long Term Goals ? – Briefly use opioids to facilitate rehabilitation and then taper off

• Personality Disorders/Psychiatric issues/Psychosocial issues ?

OPIOID MANAGEMENT

• Difficult medications to manage - Utility

• Physical Dependence

• Hyperalgesia state with withdrawal

• Potential for a paradoxical effect with chronic use

Education• 1. If rapid tolerance develops unlikely to be

a long-term solution to the patients pain state.

• 2. If the patient has an injury that needs time to heal if they take opioids they may not get the proper feedback on biophysical pain mechanisms.

• 3. Opioids are typically not a solution to a pain state, so to use opioids ONLY without other treatments will likely lead to tolerance and increasing doses……..poor pain control

• 4. Long-term use seems to loose its efficacy and the side effects of opioid remain. (cognitive delay, constipation)

• 5. I do not want to see you suffer and I will treat your pain, but I want you to understand the risks and limitations of these medications.

Rehabilitation

Middle Road of Activity

Over Activity

Under Activity

PAIN

PAIN

TIME

Urine Drug Screen

• Needs to be random

• Test temperature of urine

• Most Urine Drug screens were developed for illicit use of drugs

• More challenges and more variables when testing for compliance of narcotic use

• (hydration, dosing, metabolism, body mass, urine pH, duration of use, drug’s pharmacokinetics)

Urine drug screen

• Opiates• Codiene• Hydrocodone• Hydromorphone• Morphine

• Semi-synthetic opiates• Oxycodone• Oxymorphone

• Synthetic-methadone, Fentanyl, Tramadol• Benzodiazapines-Alprzolam, Nordiazepam• Illicit Drug-Methamphetamine, Cocaine metabolites, THCA/marijuana,

Heroin metabolite

Urine Drug Screen

• Immunoassay

• Susceptible to false positives

• Gas Chromatography-Mass Spectrometry (GC/MS)

• When a positive result is on Immunoassay then need to go to GC/MS. GC/MS is an confirmation assay that is highly reliable and specific test with rare interferences.